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Perspectives in Psychiatric Care

ISSN 0031-5990

Reaching Out To Women Who Are Victims of Intimate Partner Violence Erla Kolbrún Svavarsdóttir, RN, PhD, Brynja Orlygsdottir, RN, PhD, and Berglind Gudmundsdottir, PhD Erla Kolbrún Svavarsdóttir, RN, PhD, is Professor and Academic Chair of Family Nursing, Faculty of Nursing, University of Iceland, and is Head of Research and Development in Family Nursing, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland; Brynja Orlygsdottir, RN, PhD, is Associate Professor, Faculty of Nursing, University of Iceland, Reykjavik, Iceland; and Berglind Gudmundsdottir, PhD, is Head of Clinical Psychological Services, Mental Health Services, Landspitali-The National University Hospital of Iceland, and is Clinical Associate Professor, Faculty of Psychology, University of Iceland, Reykjavik, Iceland.

Search terms: Intimate partner violence, PTSD, physical and mental health Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. Funding The study received funds from the LUH Scientific Fund, the Scientific Fund at the University of Iceland, and the Icelandic Nurses Association Science Fund.

PURPOSE: To evaluate if disclosure of abuse among female university students and among women at an emergency department varied based on three different types of data collection method used; and to explore women’s development of symptoms of post-traumatic stress disorder (PTSD) and the outcome on health. DESIGN AND METHOD: Cross-sectional research design was used (N = 306 women). FINDINGS: The women who experienced intimate partner violence (IPV) in their current relationship, and had symptoms of PTSD, reported significantly lower physical and mental health. In addition, the women who experienced three types of abuse (physical, mental, and sexual) reported significantly more symptoms of PTSD. PRACTICE IMPLICATIONS: Detecting IPV and screening for PTSD in clinical settings might benefit women who suffer from violence in their intimate relationships.

First Received November 12, 2013; Final Revision received April 17, 2014; Accepted for publication June 26, 2014. doi: 10.1111/ppc.12080

Violence in all forms is a growing epidemic that has no boundaries. The devastating impact of intimate partner violence (IPV), in particular on women’s health and welfare (Anderson & Bang, 2012; Chouliara, Karatzias, & Gullone, 2013; Copel, 2006; Duran et al., 2009; Golding, 1999; Wilson, 2010; Wuest et al., 2010), humiliates, degrades, and injures the health, dignity, and worth of an individual. IPV has been defined by the United Nations as a behavior of an intimate partner or an ex-partner which causes physical, sexual, or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors (United Nations General Assembly, 1993). The consequences of IPV and its impact on health are well established in the literature. These include physical injuries and the development of mental illnesses, including depression, post-traumatic stress disorder (PTSD), sleep difficul190

ties, eating disorders, emotional distress, and suicide attempts (Almeida et al., 2012; Chouliara et al., 2013; Kelly, 2010; Sullivan et al., 2009; Zlotnick, Capezza, & Parker, 2011). The ICN (International Council of Nurses) Policy and Screening Procedures for IPV The International Council of Nurses (ICN) (2013) has urged a zero tolerance policy with respect to violence and has put strong emphasis on nurses taking action if they suspect a patient to be a victim of IPV. These actions include spending time talking with the women to establish the facts and then to work with them to define the support needed. They need to provide counseling and support or to seek the assistance of others in the community who can offer help and protection Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

Reaching Out To Women Who Are Victims of Intimate Partner Violence

for those affected by gender-based violence. Even though the impact of IPV on women’s health is well established in both population and clinical-based studies (Almeida et al., 2012; Chandra, Satyanarayana, & Carey, 2009; Engstrom et al., 2008; Finley et al., 2010; Kelly, 2010; Lutenbacher, 2000; Nelson, Baldwin, & Taylor, 2012; Svavarsdottir & Orlygsdottir, 2009a; Wilson et al., 2012; Woods, Kozachik, & Hall, 2010; Zlotnick et al., 2011), little is known about what screening procedures work best in clinical settings— including busy emergency departments (EDs)—and in community settings to detect IPV in current relationships (Hepworth & McGowan, 2012; Montalvo-Liendo, 2009; Montalvo-Liendo et al., 2009; Saiki & Lobo, 2011; Svavarsdottir, 2010). In a study that was to evaluate whether or not the amount of abuse varied in clinical and community settings based on the method of data collection used (e.g., written statement, oral interviewing, or electronic data collection), Catallo et al. (2012) found in a sample of 1,182 women at an ED in Ontario, Canada, that 15% of the women reported IPV, but only 2% disclosed it to healthcare professionals. Protective Role of IPV Disclosure Women who are victims of IPV need social and emotional support in order to develop resources and support networks to deal with the consequences of abuse. Interestingly, however, few researchers have studied protective factors and how they may reduce the risk of poor mental health outcomes for abused women. Coker et al. (2002) conducted a study among 1,152 women aged 18–65 years old to determine the association between IPV and mental health outcomes, as well as to evaluate the protective role of abuse disclosure and support in the women’s mental health. The main findings indicated that women who suffered from intimate partner abuse (54% of the 1,152 women) and received higher social support (e.g., therapist support, group support, friends, family, or current partner) were found to be associated with a significantly reduced risk of poor mental and physical health, anxiety, current depression, PTSD symptoms, and suicide attempts. Their findings also indicate that effective support does not need to be institutionalized or highly structured in order to be beneficial. Informal networks and spontaneous expressions of support and encouragement in both clinical practice and personal encounters can be effective in preventing further harm to women who suffer from abuse. Even though few researchers have focused on the role of protective factors, coping strategies such as seeking appropriate support among women who are victims of IPV have received more attention. Krause et al. (2008) studied the use of avoidant or approach coping strategies in a sample of 262 women who were exposed to IPV within the previous month. In the study, avoidant coping was perceived as a behavior Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

which was oriented away from the stressor or one’s reactions to it (e.g., denial, behavioral avoidance, and wishful thinking). The women who used approach coping, however, indicated responses that were directed toward the stressor or one’s reaction to it through active behaviors like problem solving and seeking appropriate support. The authors found more perceived social support to be associated with fewer PTSD symptoms among the victims, and found that women who reported more avoidant coping also reported more symptomatology. Furthermore, screening, counseling, and formal and informal support were reported to be useful for pregnant women who were in IPV relationships (Engnes, Lidén, & Lundgren, 2013). Support through the use of technology has also been found to be of benefit to abused women. Constantino et al. (2007) found email interactions to be a feasible and acceptable way of providing support and information to women who were survivors of abuse. Symptoms of PTSD and Seeking Help Interpersonal trauma has been found to be more strongly related to PTSD than most other traumatic events, and women who are victims of violence by an intimate partner have been found to be more likely to suffer from PTSD (Sullivan et al., 2009). In a systematic literature review, Scott-Tilley, Tilton, and Sandel (2010) found PTSD to be associated with impaired immune function, obesity, increased risk of diabetes, increased severity of premenstrual syndrome symptoms, depression, suicide, and increased likelihood of re-abuse. In addition, Sullivan et al. (2009) found frequency of physical, sexual, and psychological IPV to be significantly related to post-traumatic stress (PTS) and drug problems. The above findings emphasize the need for interventions to prevent and target PTS in order to reduce health problems among women who are victims of violence in their intimate relationships. Therefore, trained healthcare professionals need to be aware of the symptoms in order to respond more effectively to domestic violence as well as to prevent reoccurrence. Domestic violence training and professional skills have been found to be associated with increasing the comfort level among healthcare professionals when intervening with women who have been victims of IPV (Bacchus, Mezey, & Beweley, 2003; Bell et al., 2008; Donohoe, 2010; Goldblatt, 2009; McCay et al., 1997; Phillips, 2011; Svavarsdottir & Orlygsdottir, 2009b). The process of seeking help from healthcare professionals among women who were victims of IPV was studied by Prosman, Lo Fo Wong, and Lagro-Janssen (2013). They found lack of self-awareness of the impact of the abuse on the women themselves and on their children, unfamiliarity with available options for assistance, negative experiences with professionals, and fear of their partner to be indicative of hindrances in seeking professional help. Blasco-Ros, 191

Reaching Out To Women Who Are Victims of Intimate Partner Violence

Sánchez-Lorente, and Martinez (2010) found women who were exposed to psychological IPV alone needed more help to escape from IPV and to recapture their mental health than the women who were subjected to both physical and psychological IPV. Psychological distress and mental problems in 14 assaulted Swedish women who had left their relationships were studied by Lindgren and Renck (2008). They found that violence created long-term psychological stress reaction, but that women with high salutogenic factors that protect human beings in high-stress situations, such as sense of coherence (SOC), were found to have lower psychological distress than women with low SOC. Conceptual Framework The Women’s Response to Battering Model (Campbell & Soeken, 1999) was the conceptual framework for the study. In this model, health is considered to be the outcome variable that is influenced by physical, emotional, and/or sexual abuse, by self-care (self-esteem that is considered to be a foundational characteristic), and by motivation and energy (power components). The model focuses on the direct and the indirect effects of abuse on women’s health, mediated through a self-care agency as a protective factor (Campbell & Soeken, 1999). Increased physical and nonphysical abuse were found to result in increased health problems for women while enhanced self-care was found to result in decreased health problems, demonstrating that increased self-care agency (self-esteem, motivation, and energy) may be an effective intervention to improve health among women who are victims of abuse. Based on the conceptual framework that guided the study and on review of the literature, we hypothesized that (a) women who were current victims of IPV and had developed symptoms of PTSD would report significantly lower physical and mental health than the women who had experienced current IPV but had not experienced symptoms of PTSD; (b) women who were victims of more severe current IPV and had cumulative experience of abuse would report significantly more symptoms of PTSD than the women who were victims of less severe current IPV; and (c) women who experienced three types of abuse would report significantly worse mental and physical health than the women who experienced one type of abuse. The following research question was asked: What is the difference in disclosure of abuse in clinical and community settings based on the method of data collection used (e.g., the paper and pencil format, interviewing, and electronic data gathering)? Methods Design and Sample A cross-sectional research design was used. Data were collected from April to December 2009 from 306 women ranging 192

from 18 to 67 years old. Three methods of data collection were used. The study was conducted by data collectors at the University Square (US) and at the ED; and after signing a consent form, all participants filled out a questionnaire, in paper and pencil, with their background information as well as physical and mental health status (SF-36). The women were then randomly assigned to answer questions regarding IPV in current relationships (Women Abuse Screening Tool [WAST]) and symptoms of PTSD through three different methods of data collection. These were (a) self-report (n = 53 at the US; n = 44 at the ED), (b) computer format (n = 53 at the US; n = 48 at the ED), and (c) face-to-face interview format (n = 60 at the US; n = 48 at the ED). These methods of data collection were chosen since it had been reported in the literature (Svavarsdottir, 2010) that disclosure of abuse varied based on the method of data collection used. The data collectors (10 nurses at the ED) and the two research assistants (RAs) at the US explained the study to the women. Their partners waited outside the examination rooms at the ED (flyers explaining the study had also been posted in the women’s restrooms in the ED) and the RAs explained the study for female university students at a US without their partners being present. Of the 328 women who were introduced to the study, 4 rejected participation (giving no specific reason), leaving the sample with 324 (98.78% participation rate). However, out of the 324 questionnaire packages that were distributed to the women, forms from 18 women were incomplete, and therefore unusable, leaving the sample with data from 306 women (93% of the original sample participated in the study). All the women who agreed to participate were reminded that the study would take place in two phases. A self-report questionnaire would be given to them, and then they would be invited to continue to participate by either (a) filling out a paper and pencil questionnaire regarding IPV in their current relationships and about development of symptoms of PTSD, (b) filling out the same set of questions on a computer, and (c) having an interview with a nurse in a separate interview room at the ED or at the US. It took the women about 15–30 min to answer the two questionnaires and each interview lasted 5–30 min. Ten of 65 nurses (15.4%) working at the ED at the Landspitali University Hospital and three data collectors who worked on data collection at the US were trained in data collection having participated in previous research programs by the same principal investigator. They attended lectures about violence against women, watched a 90-min film for healthcare professionals on IPV, and participated in two to five seminars on how to use newly developed and modified clinical guidelines in their practice to identify abuse and offer best practice first response. All the women who responded positively to the questions regarding IPV in their marital/intimate relationships, no matter which method of data collection was used, were offered free consultation by a team of psychologists and Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

Reaching Out To Women Who Are Victims of Intimate Partner Violence

advanced crisis nurses who were employed at the Crisis Center at the Landspitali National Hospital. The inclusion criteria for the study were that the women were (a) 18–67 years of age, (b) seeking healthcare services from the ED, or (c) located in the community at a US, and (d) able to read and write Icelandic or English. Women were excluded from the study if they were under the influence of alcohol, had taken an overdose of medicine, or used illegal drugs. Instruments Information regarding the demographics, the women’s perception of the amount of tension, difficulty in resolving arguments and occurrence of abuse in their current intimate partner relationships, information regarding symptoms of PTSD, and the women’s physical and mental health was originally gathered from questionnaires. However, the information regarding IPV (the WAST instrument) and symptoms of PTSD were gathered either in a paper and pencil format, through electronic data collection, or in an interview. The women received exactly the same set of questions despite the data collection method used. The instruments had been translated from English into Icelandic by a group of healthcare professionals, the researchers, and a linguist specialist, and then translated back into English to establish validity and understanding, and at the same time to ensure cultural sensitivity. The instruments had been pilot tested on a group of 20 women at the ED and had been used in prior research by the principal investigator (Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2008, 2009b). Socio-Demographic Information. The socio-demographic instrument was developed by two of the investigators (Svavarsdottir & Orlygsdottir, 2006). Demographic information such as their age, education, and marital/intimate status was gathered from the women who were located at the US and from the women who were seeking healthcare services at the ED (13 items). The women were also asked about their ethnicity and employment. The WAST. The WAST was developed by Brown, Lent, Schmidt, and Sas (2000) and is used to screen for abuse in current marital/partner relationships. The instrument consists of eight items. The two first questions assess on a scale of 1 (no tension/no difficulty) to 3 (a lot of tension/great difficulty) the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments. The remaining six questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences of physical, emotional, and sexual abuse on a scale from 1 (often) to 3 (never). The WAST items are re-coded and Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

summed up to calculate the overall score. Cronbach’s alpha for the Icelandic version of the WAST has been reported to be between 0.77 and 0.97 (Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2008, 2009b). The Primary Care Post-Traumatic Stress Disorder (PC-PTSD) Screening Tool. The PC-PTSD screening tool (Prins & Ouimette, 2004) is a four-item scale that was developed to screen primary care or similar settings for symptoms of PTSD. The instrument has been used as a screening tool at Veterans Hospitals in the United States. This screening tool includes four statements, each of which corresponds to one of the four factors associated with the PTSD construct (i.e., experiencing, avoidance, numbing, and hyperarousal) (Foa, Riggs, & Gershuny, 1995; McDonald et al., 2008).Each item is endorsed in a yes/no format, and scores range from 0 to 4. The PC-PTSD has demonstrated good test–retest reliability (Prins et al., 2003). If participants respond positively to two out of the four items on the scale, then the individuals need to be evaluated further by receiving a thorough assessment interview for PTSD. Cronbach’s alpha for this Icelandic data set was 0.861. SF-36 Short-Form Health Survey. The SF-36 Short-Form Health Survey is a multipurpose, short-form health survey with 36 questions (McHorney, Ware, & Raczek, 1993). It is a widely used measure of health-related quality of life (QOL) due to its sound psychometric performance and usefulness in monitoring health outcomes for both general and specific health condition populations. The SF-36 measures functional health and well-being that consists of an eight-scale health domain score profile, which includes physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotion (RE), and mental health (MH). The physical component summary score is created by combining the PF, RP, BP, and GH subscales, and the mental component summary score is created by combining the VT, SF, RE, and MH subscales. Higher scores are indicative of better health. The SF-36 has good reliability (ICC = 0.87) (Ware et al., 2007a) and good construct validity (as measured with factor analysis) (Ware et al., 2007b). The norm-based measures have a population mean of 50 and a standard deviation of 10. Procedure The study was approved by the National Bioethics Committee of Iceland, from the Nursing Director and the Medical Director at the ED-LUH, the Chief Nurse Executive at the LUH, and the Chief Medical Executive at the LUH, and was reported to the Icelandic Data Protection Authority. The women participating in the study received oral and written introduction as to the purpose and the procedures of the study before being recruited. Women who entered the ED for healthcare services 193

Reaching Out To Women Who Are Victims of Intimate Partner Violence

and women who participated at the US were introduced to the study by the data collectors. If the women were interested in participating, they received an introduction letter regarding the study. Women who agreed to participate and gave their written consent received the questionnaire package (the background questions and the SF-36 instrument) and were then randomly assigned to receiving the WAST instrument regarding their current IPV and the PC-PTSD instrument through one of the three data collector procedures (paper and pencil, electronic, interview). However, only the women who were experiencing IPV in their current relationship were asked to answer the PC-PTSD questions. Data Analysis The data met assumptions of normal distribution as indicated by histograms and P-P plots of standardized residuals. Descriptive statistics were computed on the demographic characteristics and major study variables (e.g., relationship tension, amount of difficulty when working out arguments, frequency of abuse, symptoms of PTSD, and physical and mental health). Chi-square tests and independent t tests were conducted to test for significant differences in the women’s experiences of current IPV based on the site (ED or US). Further, independent t tests were used to test for significant differences in means of IPV on women’s physical and mental health outcomes (SF-36) based on the women’s experiences of symptoms of PTSD or not, and on the differences in means of IPV and cumulative experience of the abuse in current relationships on the women’s experiences of symptoms of PTSD. In addition, one-way analysis of variance (ANOVA) was conducted to test the hypotheses about the difference in health outcomes (SF-36) among the women who experienced IPV based on the magnitude or the cumulativity of the abuse in current relationships. The alpha level was set at 0.05 to reduce the likelihood of committing a type I error. Results Participants’ Characteristics, Health Status, Cumulativity of Abuse, and PTSD Symptoms Of the 306 women who participated in the study, 166 participated at the US and 140 participated at the ED. No significant difference was found in the proportion of frequency of disclosure of abuse as reported by the women based on the method of data collection that was used (paper and pencil, electronic, interview), either among the women at the US or those at the ED. Fifty-five women (18%) out of the 306 women who participated at the US and at the ED experienced IPV in their current relationship. Out of those 55 women, 16 (29%) participated 194

at the US and 39 (71%) participated at the ED. There were no significant differences found in the proportion of data collection method used based on the data collection site, or on the women’s age range, nationality, marital/intimate status, educational level, or the number of children at home. Furthermore, no significant difference was found in these 55 women’s health status by site, such as whether they smoked or not, misused medication or alcohol, or used drugs, nor on their perception of their own physical and psychological health (see Table 1). Additionally, no significant difference was found in the proportion of women at the US and at the ED regarding the cumulativity of the abuse (one type, two types, or three types of abuse), whether they experienced symptoms of PTSD or not, nor regarding how many PTSD symptoms they experienced (see Table 1). The Differences in Means of IPV on Physical and Mental Health (SF-36) Out of the 55 women who experienced abuse in their current marital/partner relationships (WAST), 17 (31%) also reported symptoms of PTSD (PC-PTSD). When the differences in means of the IPV were evaluated (WAST), the women who were abused in current marital/partner relationships and reported symptoms of PTSD were found to report significantly lower physical health (summary score) (mean PTSD symptoms [PTSDs] = 55.24, mean not PTSDs = 69.90; t = −2.39; p = .020) and also significantly lower mean on the subscales of RP (mean PTSDs = 51.84, mean not PTSDs = 72.40; t = −2.63; p = .011) and BP (mean PTSDs = 46.29, mean not PTSDs = 66.00; t = −2.60; p = .012) when compared to the women who experienced abuse but did not report symptoms of PTSD. These women reported a significantly greater number of problems with work or other daily activities that limited their daily activities, indicating generally poorer physical health than the women who were abused but did not report symptoms of PTSD (see Table 2). Furthermore, the women who experienced IPV (WAST) in their current marital/partner relationships and reported symptoms of PTSD were also found to report on both the summary score and on all of the subscales of the mental health scale a significantly lower mental health; that is, lower mental health summary score (p = .000), lower VT (p = .002); SF (p = .000); RE (p = .000); and mental health (p = .000) when compared to the women who experienced abuse but did not report symptoms of PTSD (see Table 2). These women reported feeling tired and worn-out all the time, had frequent and extreme interference with normal social activities due to physical and emotional problems, experienced difficulties with work or other daily activities as a result of emotional problems, and had a feeling of nervousness and depression all the time; that is, they rated their mental Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

Reaching Out To Women Who Are Victims of Intimate Partner Violence

Table 1. Demographical and Health Status Information Among the Women Who Experienced Intimate Partner Violence (n = 55) in Current Relationship Out of a Sample of 306 Women Who Participated in the Study (n = 166 Women Participated at the US; n = 140 Women Participated at the ED) US Variables Type of response Interview Paper and pencil Computer Age (years) 18–25 26–35 36–45 46–55 56–65+ Nationality Icelandic Other Marital status Married/cohabiting Separated Education Secondary High school University Children at home Yes No Smoke Yes No Misuse of medication/alcohol or using drugs Yes No Physical health Very good Good Kind of okay Bad Psychological health Very good Good Kind of okay Bad Cumulative experience of abuseb One type Two types Three types PTSD No Yes PTSD 0 1 2 3 4 a

na

ED %

Test statistics

na

%

Chi-square/ Mann–Whitney 0.328

p value

4 5 7

25.0 31.3 43.8

12 13 14

30.8 33.3 35.9

5 6 2 3 0

31.3 37.5 12.5 18.8 0.0

5 14 7 7 7

12.8 35.9 17.9 17.9 15.4

15 0

100.0 0.0

37 2

94.9 5.1

0.799

.371

16 0

100.0 0.0

31 8

79.5 20.5

3.841

.050

2 4 10

12.5 25.0 62.5

10 13 13

27.8 36.1 36.1

11 5

68.8 31.3

31 6

83.8 16.2

1.535

.215

5 11

31.3 68.8

17 22

43.6 56.4

0.720

.396

1 15

6.3 93.8

4 29

10.3 74.4

3.195

.202

4 10 1 1

25.0 62.5 6.3 6.3

6 17 9 7

15.4 43.6 23.1 17.9

220

.067

3 11 1 1

18.8 68.8 6.3 6.3

7 17 11 4

17.9 43.6 28.2 10.3

248

.195

14 2 0

93.3 13.3 0

22 10 7

57.9 26.3 18.4

3.265

.195

8 3

72.2 27.3

23 14

62.2 37.8

0.414

.520

7 1 1 0 2

46.7 6.7 6.7 0 13.3

17 6 4 4 6

44.7 15.8 10.5 10.5 15.8

218

205

165

.849

.072

.077

.240

n varies due to missing data. bYates’ chi-square. ED, emergency department; PTSD, post-traumatic stress disorder; US, University Square.

Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

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Variables Physical health summary score PTSD Not PTSD Physical functioning PTSD Not PTSD Role physical PTSD Not PTSD Bodily pain PTSD Not PTSD General health PTSD Not PTSD Mental health summary score PTSD Not PTSD Vitality PTSD Not PTSD Social functioning PTSD Not PTSD Role emotion PTSD Not PTSD Mental health PTSD Not PTSD

N

M

SD

SE mean

t

p value

17 38

55.24 69.90

22.733 20.198

5.514 3.276

−2.394

.020

17 38

74.41 79.34

28.607 27.068

6.938 4.391

−0.614

.542

17 38

51.84 72.4

26.217 26.306

6.359 4.267

−2.635

.011

17 38

46.29 66.00

27.154 25.423

6.586 4.124

−2.602

.012

17 38

48.41 62.24

26.912 24.376

6.527 3.954

−1.883

.065

17 38

36.61 67.72

16.679 15.839

4.045 2.569

−6.623

.000

17 38

38.60 54.93

18.253 17.264

4.427 2.801

−3.186

.002

17 38

39.71 70.07

24.699 27.035

5.991 4.386

−3.948

.000

17 38

31.37 78.51

23.668 23.936

5.740 3.883

−6.772

.000

17 38

36.76 67.37

16.002 19.198

3.881 3.114

−5.734

.000

Table 2. The Differences in Means of IPV on Women’s Physical and Mental Health Outcomes (SF-36) (n = 55) Based on the Women’s Experiences of Symptoms of PTSD or Not

IPV, intimate partner violence; PTSD, post-traumatic stress disorder.

health as significantly poorer than the women who were abused but did not report symptoms of PTSD (see Table 2). Differences in Means of IPV (WAST) on PTSD When the differences in means of IPV (WAST) were evaluated further, the women who experienced a higher magnitude of abuse (had higher mean score) were also found to experience symptoms of PTSD. This was the case for both the WAST short scale (0–2) (mean PTSDs = 0.82, mean not PTSDs = 0.03; t = 3.65; p = .002) and the WAST total scale (8–24) (mean PTSDs = 17.35, mean not PTSDs = 12.58; t = 6.61; p = .000). In addition, the women who experienced cumulative abuse (physical and/or emotional and/or sexual abuse) and had higher magnitude of abuse (had higher mean score) reported symptoms of PTSD (see Table 3). ANOVA Results: Difference in Health Outcomes (Physical and Mental Health) Based on the Magnitude or the Cumulativity of the Abuse in Current Intimate Relationships When the differences in the means of cumulative experience of abuse were evaluated in the women’s physical health, 196

those who experienced three types of abuse (physical, emotional, and sexual) were found to report significantly lower mean scores on the subscale of RPs than the women who experienced one type of abuse (one type of abuse mean = 72.22; two types of abuse mean = 63.02; three types of abuse mean = 37.50; F = 5.46; p = .007), indicating the women who experienced three types of abuse reported significantly more problems with work or other daily activities as a result of their physical health (see Table 4). Similarly, the women who experienced three types of abuse (physical, emotional, and sexual abuse) were also found to report significantly lower mean scores on the subscale of RE on the mental health scale than the women who experienced one type of abuse (one type of abuse mean = 70.60; two types of abuse mean = 59.72; three types of abuse mean = 36.90; F = 3.65; p = .033), thus indicating that these women experienced problems with work or other daily activities as a result of their emotional problems. Discussion The main findings from this study contribute to new understanding regarding disclosure of abuse, detecting symptoms Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

Reaching Out To Women Who Are Victims of Intimate Partner Violence

Table 3. The Differences in Means of IPV (WAST) and Cumulative Experience of the Abuse in Current Relationship on the Women’s (n = 55) Experience of Symptoms of PTSD

Variables

N

WAST short (0–2) PTSD Not PTSD WAST total (8–24) PTSD Not PTSD Cumulative experience of abuse (physical and/or emotional and/or sexual abuse) PTSD Not PTSD

M

SD

SE mean

t

p value

17 38

0.82 0.16

0.883 0.370

0.214 0.060

2.994

.008

17 38

17.35 12.42

2.691 1.687

0.653 0.274

6.968

.000

17 38

1.94 1.08

0.827 0.749

0.201 0.122

3.821

.000

IPV, intimate partner violence; PTSD, post-traumatic stress disorder; WAST, Women Abuse Screening Tool.

of PTSD, and exploring the differences in means of current IPV on women’s health and QOL both in a general population sample among young female university students and in a specific clinical population sample. For clinicians, knowing that brief, but reliable and valid screening tools, such as the eight-item WAST instrument and the four-item PC-PTSD screening tool, can be used within reasonable time both at a busy ED and in a community setting that is of great value to nurses. Furthermore, these tools can be used to fulfill the ICN (2013) emphasis on zero tolerance policy in clinical work settings on gender violence. Even though these two screening tools are brief, they give nurses information about IPV in close relationships and an indication of PTS. Therefore, detecting IPV and offering, as a healthcare professional, appropriate first response and support is valuable and can be beneficial for women who are victims of current IPV. Following the screening, healthcare professionals can therefore use the information from the screening procedure immediately in the clinic to offer appropriate support, assistance, consultation, and/ or protection. Additionally, knowing that there was no difference found in the frequency of disclosure of IPV based on the method of data collection used is also new knowledge in the literature and of great value in clinical practice. Healthcare professionals can recommend that women who were screened positively for PTS receive a more detailed assessment of the symptoms of PTSD and other potential consequences of the abuse. Importantly, knowing that there was no difference found in the frequency of disclosure of IPV based on the method of data collection, nor by the site (clinical vs. community setting), is also new knowledge in the literature and of great value in clinical practice. This information gives nurses the possibility to choose the method that would best fit their clinical practice; that is, to use either the paper and pencil format, the computer, or an interview when administering these screening tools to detect IPV and symptoms of PTSD. Interestingly, even though the two sites where the data collection took place varied quite a bit (community setting vs. ED), there was no significant difference found Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

in the women who suffered from current IPV by site, with respect to how they perceived their own health, their experience of cumulativity of abuse, or their experience of symptoms of PTSD. The findings from the hypotheses testing regarding the differences of means of IPV in current marital/intimate relationships based on the women’s symptoms of PTSD and the outcome on the women’s physical and mental health are supported in the literature (Kelly, 2010; Wilson et al., 2012; Zlotnick et al., 2011). In our study, about one third of the women who reported they were victims of IPV in current marital/intimate relationships also reported symptoms of PTSD. This finding is in harmony with findings reported by Golding (1999), who found in a meta-analysis that between 31% and 84% of women who were victims of IPV developed numerous mental health consequences, including PTSD. Furthermore, the women who suffered from violence in current marital/partner relationships and reported symptoms of PTSD were also found to report significantly lower physical and mental health than the women who were victims of current IPV but did not report symptoms of PTSD. In addition, when the differences in the means of IPV were evaluated further, the women who experienced a higher magnitude of abuse and had experienced cumulativity of abuse were also found to experience symptoms of PTSD. Additionally, the women who experienced psychological, physical, and sexual abuse (three types of abuse) reported significantly lower RP and lower RE, indicating these women experienced more problems with work or other daily activities as a result of their emotional problems than the women who experienced one type of abuse. These findings are supported in the literature and are in harmony with findings reported by Sullivan et al. (2009) and Scott-Tilley et al. (2010), who found the frequency of emotional, physical, and sexual abuse to be significantly related to PTSD, and PTSD to be significantly related to health problems. IPV is a destructive traumatic life experience that can leave behind higher levels of anxiety, stress, and overuse of 197

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Table 4. One-Way ANOVA Results Regarding the Difference in Health Outcomes (Physical and Mental Health, SF-36) Among the Women Who Experienced IPV (n = 55) Based on the Magnitude or the Cumulative of the Abuse in Current Relationship Variables Physical health Physical functioning One type of abuse Two types of abuse Three types of abuse Role physical One type of abuse Two types of abuse Three types of abuse Bodily pain One type of abuse Two types of abuse Three types of abuse General health One type of abuse Two types of abuse Three types of abuse Mental health Vitality One type of abuse Two types of abuse Three types of abuse Social functioning One type of abuse Two types of abuse Three types of abuse Role emotion One type of abuse Two types of abuse Three types of abuse Mental health One type of abuse Two types of abuse Three types of abuse

Na

M

SD

F value (df)

p value

36 12 7

79.3 74.2 77.86

26.10 29.61 33.65

0.137 (2,54)

.872

36 12 7

72.22 63.02 37.50

25.42 25.21 27.72

5.460 (2,54)

.007b

36 12 7

63.19 55.58 50.43

24.93 29.15 36.38

0.828 (2,54)

.443

36 12 7

63.14 50.50 44.14

23.57 31.14 21.34

2.351 (2,54)

.105

36 12 7

52.95 43.75 44.64

17.45 19.22 25.11

1.380 (2,54)

.261

36 12 7

65.63 53.13 48.21

30.23 26.18 30.13

1.534 (2,54)

.225

36 12 7

70.60 59.72 36.90

30.50 34.78 23.99

3.651 (2,54)

.033c

36 12 7

58.75 60.00 57.91

22.60 26.46 23.07

0.475 (2,54)

.62

Study Limitations

a

n varies due to missing data. bPost hoc comparison using the Tukey HSD test indicated that the mean score for women who experienced one type of abuse was significantly different from the mean score for women who experienced three types of abuse (p = .005). cPost hoc comparison using the Tukey HSD test indicated that the mean score for women who experienced one type of abuse was significantly different from the mean score for women who experienced three types of abuse (p = .028).

ineffective coping strategies that do not resolve the stressor. Therefore, detecting IPV in current marital/intimate relationships is of vital importance in order for women to begin to deal with the consequences of the abuse. Social support (e.g., professional, family, and/or friends) and emotional support can be of fundamental importance in the recovery process. Coker et al. (2002) found that effective support for women who were suffering from IPV did not need to be 198

institutional or highly structured in order to be of benefit to them. The findings from this study highlight the importance and the validity of brief screening tools regarding detecting IPV in current marital/partner relationships and regarding identifying symptoms of PTSD. Detecting IPV in clinical settings is important in order to begin to support women who are suffering from abuse toward the road to recovery.

A general limitation of the study was that results may be biased because some women may not have revealed abuse, or those who did not respond were those who were abused. According to ICN (2013), known reasons for not revealing abuse are, for example, shame, fear, denial, or lack of trust. The design of the study was cross sectional, which limits inferences about causality. Conclusion Women who are victims of IPV in their current marital/ partner relationships need to be supported by healthcare professionals, as well as by family and friends, in dealing with the aftermath of the abuse. Receiving appropriate first response from clinical practitioners after revealing being a victim of IPV is therefore of crucial importance for women in order to decrease the likelihood of re-abuse and to start working toward the process of healing. The findings from this study highlight the health consequences that current IPV and symptoms of PTSD have on young and middle-aged women’s well-being and QOL. By raising the awareness of the devastating impact of IPV on women’s welfare and health, and by assessing for current IPV and symptoms of PTSD in clinical settings, such as by using brief screening tools, nurses can start to reach out toward women who are victims of IPV by empowering and supporting them. Early detection of IPV and symptoms of PTSD might make the difference in women’s lives. Implications for Nursing Practice Professional participation in the development and use of clinical guidelines for women who are victims of current IPV needs to be facilitated both at primary healthcare settings as well as at EDs. Furthermore, being up to date in new knowledge regarding the impact of IPV on women’s welfare and health and on what psychosocial interventions are of most benefit to women who are victims of intimate abuse can be vital. In order to offer evidence-based practice to women who are exposed to IPV in current marital/partner relationships, advanced nurse practitioners need to be able to adequately support these women. In addition, empowering women who are victims of IPV to use self-management techniques to cope Perspectives in Psychiatric Care 51 (2015) 190–201 © 2014 Wiley Periodicals, Inc.

Reaching Out To Women Who Are Victims of Intimate Partner Violence

with the aftermath of the abuse can be critical easing or softening the recovery approach. Detecting current IPV in clinical settings can be the first step in working toward preventing reoccurrence or ending the abuse. Identifying IPV in healthcare settings and referring them to advanced practitioners such as advanced psychiatric mental health nurses might also be important. Advanced psychiatric mental health nurses can play a major role in offering appropriate support and interventions which might ease the healing process and facilitate better health for women who are victims of IPV in their current intimate relationships. Acknowledgments The authors would like to thank all the women who participated in this study; learning from them was very meaningful to us. We would also like to give special thanks to Gudbjorg Palsdottir at LUH for her participation in facilitating the data collection process at the emergency department at LUH. All the nurses at the emergency department who participated in the data collection are specially thanked, and also Lilja Þórunn Þorgeirsdóttir, a BSc nurse, for participating in the data collection process at the University Square. References Almeida, C. P., Cunha, F. F., Pires, E. P., & Sá, E. (2012). Common mental disorders in pregnancy in the context of interpartner violence. Journal of Psychiatric and Mental Health Nursing, 20, 1–7. Anderson, K. M., & Bang, E. (2012). Assessing PTSD and resilience for females who during childhood were exposed to domestic violence. Child & Family Social Work, 17, 55–65. Bacchus, L., Mezey, G., & Beweley, S. (2003). Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health and Social Care in the Community, 11, 10–18. Bell, M. E., Cattaneo, L. B., Goodman, L. A., & Dutton, M. A. (2008). Assessing the risk of future psychological abuse: Predicting the accuracy of battered women’s prediction. Journal of Family Violence, 23, 69–80. Blasco-Ros, C., Sánchez-Lorente, S., & Martinez, M. (2010). Recovery from depressive symptoms, state anxiety and post-traumatic stress disorder in women exposed to physical and psychological, but not to psychological intimate partner violence alone: A longitudinal study. BMC Psychiatry, 10, 2–12. Brown, J. B., Lent, B., Schmidt, G., & Sas, G. (2000). Application of the Woman Abuse Screening Tool (WAST) and WAST-short in the family practice setting. Journal of Family Practice, 49, 896–903. Campbell, J. C., & Soeken, K. L. (1999). Women’s responses to battering: A test of the model. Research in Nursing and Health, 22, 49–58.

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